scholarly journals Description Of Factors Affecting Delay Return Of Hospitalization Medical Record

2021 ◽  
Vol 1 (1) ◽  
Author(s):  
Linda Handayuni ◽  
Dewi Mardiawati ◽  
Ririn Afrima Yenni ◽  
Elda Nelfia
Keyword(s):  
Human Resources ◽  
Medical Record ◽  
Medical Records ◽  
Research Method ◽  
Rate Of Return ◽  
Inclusion Criteria ◽  
Literature Study ◽  
Factors Affecting ◽  
And Training

Background: The restoration of medical records is an important part of the medical record unit, because it is the beginning of activities before the start of processing the patient's medical records. Many factors influence the delay in returning medical records, namely the medical resume form sheets that have not been filled in completely by doctors and nurses who handle patients and the lack of good responsibility in returning inpatient medical records. The purpose of this literature study is to determine the factors that influence the delay in returning hospitalized medical records.Methods: The research method used is literature study with data search using google shoolar. The inclusion criteria used were journals to determine the factors that influenced the delay in returning fully accessed inpatient medical records.Results: The results of the literature study show that the rate of delay in returning inpatient medical records is still high 50%, late which is influenced by 44.4% poor responsibility for returning medical records, and doctor's discipline in filling in complete 70% complete medical resume.Conclusions: Based on the results of this study, it can be concluded that the rate of return of medical records in hospitals is still high. Researchers suggest cooperation between nurses and doctors in filling and returning medical records to improve the quality of hospital medical records, as well as the need to improve human resources and training.

Study of Incompleteness Medical Records of Inpatient in Appendicitis Cases at Dr. Reksodiwiryo Hospital Padang

2022 ◽  
Vol 2 (1) ◽  
pp. 39-44
Author(s):  
Nurhasanah Nasution
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Research Method ◽  
Digestive Surgery ◽  
Diagnostic Codes ◽  
Diagnosis Codes ◽  
Service Information ◽  
Incomplete Filling ◽  
Existing Data

Background: Incomplete filling of medical record files for inpatients at Dr. Reksodiwiryo hospital medical records will be describe health services and the quality of medical record services. Medical record quality services include the completeness of medical record files, accuracy in providing diagnosis and diagnosis codes, as well as speed in providing service information. The requirements for quality medical records must be accurate, complete, reliable, valid, timely, usable, common, comparable, guaranteed, and easy.Methods: This research method is a descriptive with a retrospective approach or looking at existing data. This study was carried out in September 2021. The population was 70 files cases of inpatient digestive surgery. Samples were taken from 27 files of inpatients with appendicitis cases.Results: From the research that has been done, the highest percentage of incomplete identification components is found on the gender item about 81.48%, the highest percentage of incomplete important report components is obtained on the medical resume and informed consent items about 11.1%. The highest percentage of incomplete authentication components was obtained in the nursing degree about 96.3%. The highest percentage of the components of the recording method was obtained by 59.3%, there are several blank sections about 16 files. The percentage of incomplete diagnostic codes and procedures is 100%  Conclusions: the researcher suggested that the hospital can have an Operational Standart on filling out the completeness of medical records files

scholarly journals PENGARUH KELENGKAPAN PENGISIAN FORMULIR TRANSFER PASIEN INTERNAL TERHADAP MUTU REKAM MEDIS

2021 ◽  
Vol 10 (2) ◽  
pp. 124-131
Author(s):  
Indar Farwanti Wahyuni
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Random Sampling ◽  
Health Workers ◽  
Sampling Technique ◽  
Simple Random Sampling ◽  
Patient Transfer ◽  
Literature Study ◽  
Number Of Patients

Abstract Internal patient transfer is the process of transferring patients from one room to another in a hospital while still being oriented towards quality and patient safety. The results of the observations showed that the filling of the internal patient transfer form was not optimal so that there were still incomplete forms due to the large number of patients and the weak coordination between health workers. To determine the effect of the completeness of filling out the internal patient transfer form on the quality of medical records. The research method used is quantitative with a descriptive approach. Data collection techniques used are observation, questionnaires and literature study. The sampling technique was simple random sampling technique so as to obtain a sample of 91 internal patient transfer forms. From the results of observations, 22% of the internal patient transfer forms were found that were not completely filled in, especially in the signature and clear name. The two variables have a strong relationship. The effect of the variable completeness of the internal patient transfer form on the medical record quality variable is 90.1% and the remaining 9.9% is influenced by other factors. Based on these studies, it can be concluded that the lack of accuracy and coordination of nurses, doctors and other officers in filling out internal patient transfer forms so that this affects the quality of medical records in the aspect of accuracy. Keyword : Completeness, Internal Patient Transfer Form, Medical Record Quality   Abstrak Transfer pasien internal merupakan proses pemindahan pasien dari satu ruangan ke ruangan yang lain di dalam satu rumah sakit dengan tetap berorientasi pada mutu dan keselamatan pasien. Hasil observasi menunjukkan bahwa belum optimalnya pengisian formulir transfer pasien internal sehingga masih terdapat formulir yang tidak lengkap disebabkan oleh faktor dari banyaknya pasien dan lemahnya koordinasi antara tenaga kesehatan. Untuk mengetahui pengaruh kelengkapan pengisian formulir transfer pasien internal terhadap mutu rekam medis. Metode penelitian yang digunakan yaitu kuantitatif dengan pendekatan deskriptif. Teknik pengumpulan data yang digunakan adalah observasi, kuesioner dan studi pustaka. Teknik pengambilan sampel adalah teknik simple random sampling sehingga memperoleh sampel sebanyak  91 formulir transfer pasien internal. Dari hasil observasi ditemukannya formulir transfer pasien internal yang belum terisi lengkap sebanyak 22% terutama pada tandatangan dan nama jelas. Kedua variabel memiliki hubungan yang kuat. Pengaruh variabel kelengkapan formulir transfer pasien internal terhadap variabel mutu rekam  medis sebesar 90,1% dan sisanya 9,9% dipengaruhi oleh faktor lain. Berdasarkan penelitian tersebut dapat disimpulkan bahwa kurangnya ketelitian dan koordinasi perawat, dokter dan petugas lain dalam pengisian formulir transfer pasien internal sehingga hal ini mempengaruhi mutu rekam medis pada aspek keakuratan. Kata kunci: Kelengkapan, Formulir Transfer Pasien Internal, Mutu Rekam Medis

Electronic Medical Record as Literature Study

2022 ◽  
Vol 2 (1) ◽  
pp. 45-51
Author(s):  
Yuli Mardi
Keyword(s):  
Human Resources ◽  
Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Health Care Services ◽  
Scientific Journal ◽  
Data Entry ◽  
Health Facilities ◽  
Literature Study ◽  
Planning Stage

Background: Medical records can be created manually or electronically. In the world of health, the development of information and communication technology is currently affecting health care services as a whole, including the implementation of electronic medical records. The application of electronic medical records must go through a careful planning stage, this is because electronic medical records involve many parties in health facilities and and require a lot of costs. For this reason, a comprehensive study of electronic medical records is needed. One way is to conduct a literature study of several articles related to the electronic medical record.Methods: In conducting this research, the literature review method was used, where the search for articles was not carried out systematically, but the scientific journal articles reviewed were selected by the researcher on one research topic, and selected based on the knowledge and experience possessed by the researcher (traditional review).Results: In this study, 7 articles were reviewed related to electronic medical records. There are some similarities in terms of benefits or obstacles in the application of electronic medical records in health facilities. Among the benefits of electronic medical records are the efficiency of using paper/medical record files, efficiency in the use of space/storage media, time efficiency in searching data and distributing medical record data, efficiency of human resources in finding medical record files and being able to detect errors in data entry. While some of the common obstacles to implementing electronic medical records in health facilities are the unpreparedness of officers at health facilities, so it takes time for socialization and training of human resources, problems with the network, lack of IT resources at health facilities that specifically handle electronic medical records, high implementation costs. expensive (hardware software) and there is no legal umbrella.Conclusions: There is a need for comprehensive research using the semantic review method of articles related to electronic medical records, so that the results can be used as a reference for health facilities in implementing electronic medical records. Thus, it is hoped that the migration and implementation process from manual medical records to electronic medical records can be carried out as expected.

scholarly journals Tinjauan Pelaksanaan Review Berkas Rekam Medis Sesuai Standar Manajemen Informasi Dan Rekam Medik (MIRM 13.4) Di Rumah Sakit Imelda Pekerja Indonesia Tahun 2020

2021 ◽  
Vol 6 (1) ◽  
pp. 7-13
Author(s):  
Esraida Simanjuntak ◽  
Mustamil Alwi Dasopang
Keyword(s):  
Medical Record ◽  
Information Management ◽  
Medical Records ◽  
Research Method ◽  
Medical Personnel ◽  
Education Assessment ◽  
Management Standards ◽  
Hospital Worker ◽  
Quality Of Health Services

  One of the parameters for determining the quality of health services in the hospital is data or information from good and complete medical records. Medical records are an important part of helping the implementation of service delivery to patients at the hospital. Standards relating to medical records in SNARS Edition 1 are in the group of hospital management standards, namely Medical Record Information Management (MIRM) regarding medical record document processing including provision, filling of medical records and reviewing medical records. This research method is descriptive with the method of observation. When this research was conducted in July 2020 at the Imelda Hospital Worker Indonesia Medan. The population taken was 705 medical record documents while the sample in this study was 87 medical record documents. Based on the results of the study, in the review the accuracy of returning medical record documents was 57.4% and 42.5% were incorrect. Readability review of ER assessment as much as 63.2%, assessment of Inpatient as much as 56.3%, CPPT as much as 60.9%, approval for action as much as 77%, reports of anesthesia as much as 68.9%. 3 forms of completeness review are complete, namely Education Assessment, rejection and education form (100%). Suggestions in this study are that review officers must be more assertive to remind every doctor or other medical personnel to pay attention to the accuracy of the restoration, the legibility of medical record files and the completeness of medical record documents. As well as regularly socializing the elements of the MIRM 13.4 assessment.

scholarly journals Analysis The Level of Compliance of Hospital Human Resources in Writing The Status of Inpatient Medical Record Dr Sayidiman Hospital and The Influences Factors

2020 ◽  
Vol 3 (2) ◽  
pp. 423-433
Author(s):  
Ratnawati Ratnawati
Keyword(s):  
Linear Regression ◽  
Human Resources ◽  
General Hospital ◽  
Medical Record ◽  
Health Professionals ◽  
Medical Records ◽  
Regional Hospital ◽  
P Value ◽  
The Status

The quality of medical records in hospitals also determines the quality of service, completeness of writing Medical Records documents correctly and correctly is very important. The purpose of this study was to analyze the level of compliance of hospital human resources in writing the status of the inpatient Medical Record Dr. Sayidiman Magetan Regional Hospital and the factors that influence it. The design of this study was an observational quantitative study with a cross section approach with the focus of the research directed to be analyzing the level of compliance of hospital human resources in writing the status of the inpatient Medical Record Dr Sayidiman Magetan Regional Hospital and the factors that influenced it with a sample of 192 respondents taken with the Simple Random Sampling technique. The findings found that most of the respondents have high motivation that is 144 respondents (75%). Most of the respondents care to write in the medical record that is 160 respondents (83.3%). Most of the respondents have a high appreciation of 136 respondents (70.8%). Most of the respondents did not comply doing medical record writing of 107 respondents (55.7%). Based on the Linear Regression analysis the motivation variable on compliance p-value 0.015 <0.05, the variable concern for compliance p-value 0.025 <0.05 then H0 is rejected so there is the influence of motivation and concern for compliance with medical record writing by health professionals in Regional General Hospital Dr. Sayidiman Magetan. Linear regression variable rewards for compliance shows that the p-value of 0.665> 0.05 then H0 is accepted so it is concluded that there is no effect of rewards on compliance with writing medical records by health professionals at the Dr Sayidiman Magetan Regional General Hospital. It is expected that respondents can comply to fill out medical records so that the delivery of care to passion can be well integrated

scholarly journals Description Of Medical Record Staff Based On Method Workload Indicator Staff Need In Kuningan Medical Center Hospital

2019 ◽  
Vol 6 (2) ◽  
pp. 42-50
Author(s):  
Rina Eka Aulia ◽  
M.H. Asiana Gabril ◽  
Riantina Luxiarti
Keyword(s):  
Human Resources ◽  
Medical Record ◽  
Survey Research ◽  
Medical Records ◽  
Research Method ◽  
Medical Center ◽  
Future Research ◽  
Health Work ◽  
Center Hospital ◽  
Descriptive Survey

Workload Indicator Staff Need (WISN) is a method of calculating the needs of real health human resources implemented in each health work unit. The purpose of this study is to describe the needs of Medical Record staff based on the WISN methodIn Kuningan Medical Center (KMC) Hospital. This research method is a descriptive survey research method, the population of this study is 8 medical records officers, and the sample is 8 patients and the sampling uses total sampling. The results were obtained from the WISN ratio of 10 people, namely: 3 outpatient registrations, 1 inpatient registration, 1 outpatient coding, 1 inpatient coding, 2 assembling people, and 2 filing people, so it can be concluded that there are advantages to outpatient registration and any shortages for assembling and filing. The suggestion of this research is that future research can use other methods.

Faktor-Faktor yang Mempengaruhi Mutu Pelayanan Rekam Medis di Rumah Sakit

2019 ◽  
Vol 14 (2) ◽  
pp. 59
Author(s):  
Rindi Rendarti
Keyword(s):  
Service Quality ◽  
Human Resources ◽  
Medical Record ◽  
Medical Records ◽  
Services Quality ◽  
Medical Services ◽  
Quality Of Services ◽  
Hospital Services ◽  
Incomplete Filling

Background: Medical record units as part of supporting medical services in hospitals have an important role in improving the quality of services in hospitals. The indicator of service quality in hospital is measured by incomplete inpatient medical record files. Based on several studies in various hospitals, the complete of inpatient medical record files is around 70% - 80% from 100%. Based on the preliminary data in action research in PKU Muhammadiyah hospital, there were 60 % incomplete in filling the medical resume from 100% target. There are many things that occurred, one of them are about human resources that is affected by behavior, the implementation of operational standards in filling medical records, punish and reward files. Objective: To review the factors that affect the quality of service in medical record units related to improving the quality of hospital services.  Methods: the method of this study used relevant health databases including Scholars by using a combination of  terms: hospital service quality indicators, incompleteness in filling medical medical records, quality of medical record services. Results: The result of this study said that there were related between medical record services and quality of hospital services. The quality indicator in the medical record can be able to be measured was the number of incomplete filling in medical record files. Filling of incomplete medical record files has the potential to reduce the overall quality of hospital services Keywords: quality of medical record services, quality of hospital medical services, incomplete medical record filling

scholarly journals Factors that cause compliance filling medical records in hospitals

2020 ◽  
Vol 7 (10) ◽  
pp. 4180
Author(s):  
Chamy Rahmatiqa ◽  
Nurul Abdillah ◽  
Fajrilhuda Yuniko
Keyword(s):  
Human Resources ◽  
Medical Record ◽  
Medical Records ◽  
Research Data ◽  
Recording System ◽  
The Internet ◽  
Financial Conditions ◽  
Document Review ◽  
Published Research

Hospital recording system guidelines or known as medical records. Failure to fill medical records has an impact on the quality of service and hospital accreditation. The purpose of this study is to see what factors are the cause of non-compliance in filling Medical Records in hospitals throughout Indonesia. Research is a systematic review. The source of this research data comes from the literature obtained through the internet in the form of published research results regarding the causes of the inability of medical record documents in hospitals from all journals that have been published and can be accessed via the internet. Data was collected from 15 April 2020-10 July 2020. The results of the analysis through document review showed that the factors causing non-compliance of filling medical record documents at the High Hospital were human resources which were 66.6%, there was no clear and firm policy of 33.3%, facilities that did not support were 22.2% and limited funds by 11.1%. It is expected that each hospital must have a clear and firm policy in dealing with non-compliance with filling out this medical record document. With a clear and firm policy on the condition of HR unpreparedness, the facilities and financial conditions which will also be regulated in the policy can also be overcome at the same time.

scholarly journals PERAN IKATAN PUSTAKAWAN INDONESIA (IPI) PROVINSI RIAU DALAM MENGEMBANGKAN KUALITAS SUMBER DAYA MANUSIA PUSTAKAWAN

2020 ◽  
Vol 15 (1) ◽  
pp. 115
Author(s):  
Vivi Avilia ◽  
Vita Amelia ◽  
Hadira Latiar
Keyword(s):  
Qualitative Research ◽  
Human Resources ◽  
Research Method ◽  
Education And Training ◽  
Scientific Activity ◽  
Library Management ◽  
Work Program ◽  
And Training

The Indonesian Librarian Association (IPI) Organization of Riau Province is one of the organizations that support the quality of human resources in the librarian profession, with the existence of a professional librarians organization can help librarians in improving library management to the maximum. This study aims to determine how the Role of the Indonesian Librarian Association (IPI) of Riau Province in Developing the Quality of Librarian Human Resources. The method used in this research is descriptive qualitative research method. This research was conducted by interviewing the management and members of the Riau Province Indonesian Librarian Association (IPI) based on three indicators, namely (1) Scientific Activities, (2) Education and Training, and (3) Riau Smart Program. The results of the interviews show that of the three work program indicators, the Indonesian Librarian Association (IPI) of Riau Province has not carried out its activities properly. In the Scientific Activity Indicator, IPI of Riau Province has conducted 5 activities that lead to the development of librarians' human resources. In the Education and Training Indicator, IPI of Riau Province has conducted 1 activity that leads to the development of librarian's human resources. In the Riau Smart Program Indicator, the Provincial IPI has carried out 1 activity that leads to the development of library human resources. So it can be concluded that the role of the Indonesian Librarian Association (IPI) of Riau Province in Developing the Quality of Librarian's Human Resources has not been carried out to the maximum.Keywords: Role, Librarian, Quality, Human Resources, Indonesian Librarian Association (IPI) of Riau Province.

ANALISIS PELAKSANAAN REKAM MEDIS DI RUMAH SAKIT IBU DAN ANAK (RSIA ) WIDIYANTI

2018 ◽  
Vol 11 (1) ◽  
Author(s):  
Fera Siska
Keyword(s):  
Qualitative Research ◽  
Data Analysis ◽  
Data Collection ◽  
Human Resources ◽  
Medical Record ◽  
Medical Records ◽  
Depth Information ◽  
Operational Procedure ◽  
Patient Registration ◽  
Qualitative Research Design

ABSTRACTBackground : Medical record is one of the most important pillars that can not be considered trivial in a hospital, with the development of medical scienceCommon Purpose : To find in-depth information about the implementation of medical records at the hospital Widiyanti PalembangResearch Method : Qualitative research design with data collection techniques are conducted in triangulation, The data analysis is inductive, and the results of the study are emphasized more at the meaning than the generalization. The Research Results : the Implementation of medical records have been running but there is no medical record organization, the implementation of medical record activities done by rolling. Human Resources (HR) medical records should be placed specifically in the medical record along with clear tasks. Method of organizing medical record has been run although the result is not optimal, because Standard Operational Procedure (SOP) that made not socialized. Facilities and infrastructure that support the implementation of the medical record is good, marked by the existence of a special records archive medical records. Facilities and infrastructure such as chairs, desks, computers, patient registration books and outpatient registration and inpatient services are available, do not have budget funds for medical record implementation, especially by sending medical recruiter for trainingConclusion : Implementation of medical records have been running but not optimal.

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